January 28, 2010

V. Obstacles to Abortion Access for Women Living in Ireland

There is a huge amount of hypocrisy in the Irish situation. One of the main reasons that abortion remains illegal is because they can export their problem, because women can travel.
— Ann Furedi, Chief Executive of the British Pregnancy Advisory Service, August 20, 2008

Women living in Ireland face substantive obstacles to accessing safe abortion services. The vast majority must by law travel from their homes to a foreign country to access these services. Even the women who, by law, are entitled to have an abortion in Ireland because their pregnancy threatens their life often cannot get one due to lack of information and willing providers, and a general climate of fear and uncertainty.

These general obstacles to access are further compounded for women who do not live close to sources of information and available services, adolescents, disabled women and those without financial resources, all of whom face additional challenges in planning for an expensive medical procedure abroad at a time when they are already in a state of some emotional distress. Those who cannot travel because of their immigration status, lack of money, because they are in state custody, or for any reason whatsoever are forced to choose between continuing a crisis pregnancy and accessing illegal, often risky services.

The availability of safe abortion services in other EU countries, particularly in the UK, has played a significant role in allowing the Irish government to abdicate its responsibility to protect the human rights of women who require access to abortion. As one of a very small number of doctors in Ireland who are willing to be open about supporting women’s right to decide to terminate a pregnancy told Human Rights Watch, “... if it [abortion] wasn’t so readily available, this problem would have to be solved, but having access to the UK has made it not necessary ... to not ignore it.”[27] 

Failure to Provide Access to Legal Abortions      

In the most egregious violation of women’s human rights, including to life, health, privacy, and equal protection under the law, the Irish government has failed to ensure access to abortion in even those limited circumstances where it is permitted by law.

A physician who has worked with pregnant women for a significant length of time told Human Rights Watch that she has never heard of any legal abortions being performed in Ireland. She recounted the case of a woman whose life was endangered by her pregnancy and who had to leave the country to access care, despite the fact that Irish law entitles her to an abortion at home.[28] Human Rights Watch was unable to document a single case of a legal abortion being performed in Ireland and it is clear from our interviews with doctors and medical professionals that many women who are legally entitled to access abortion services in Ireland cannot do so.[29] This situation is not in compliance with international law.

The 1994 International Conference on Population and Development(ICPD) Programme of Action was the first international consensus document to recognize that where abortion is legal, services must be provided and must meet certain standards.[30] The Programme of Action states that “[i]n circumstances where abortion is not against the law, such abortion should be safe,”[31] a sentiment that has been repeated by several treaty-monitoring bodies as well as by the UN Special Rapporteur on the Right to Health.[32] Abortion services should be provided in conformity with international human rights standards, including with regard to the adequacy and accessibility of the services.[33]

The Irish government has failed utterly to ensure that health services are available to those women who are legally entitled to an abortion. In 2005 the UN Human Rights Committee, which oversees the implementation of the International Covenant on Civil and Political Rights (ICCPR) to which Ireland is a party, examined the situation of a young girl in Peru, who was not able to access a legal abortion in a legislative context which is similar to that of Ireland. The Committee held that there had been numerous violations of the girl’s rights as a result of the failure to provide access to legal abortions. In the specific case examined by the Committee, a pregnant adolescent had been forced to continue with an anencephalic pregnancy.[34] The Committee found that the “treatment forced upon this young girl constituted a violation of her rights to be free from inhuman and degrading treatment, to private life, to such measures of protection as are required by her status as a minor, and to her right to an effective remedy.”[35]  

The United Nations Committee against Torture (CAT), which oversees the Convention Against Torture to which Ireland is also a party, has also described the in ability to access abortion in a situation of a life threatening pregnancy as a violation of human rights.[36]

In April 2008, the Commissioner for Human Rights for the Council of Europe, following a visit to Ireland, highlighted the failure of the Irish government to ensure access to legal abortion and called on the government to ensure that adequate services were in place to carry out legal abortions in Ireland.[37] The UN Human Rights Committee has also expressed its concerns about obstacles to abortion where it is legal, and the fact that women may be forced to go abroad for an abortion. The Committee has explicitly noted that no woman should be forced to go through with a pregnancy which would mean her suffering inhuman or degrading treatment. [38]

In Ireland, the very divisive public debate on abortion in the context of a small country with a limited number of practicing obstetrics and gynecology specialists, all of whom know of each other, has also limited the availability of legal abortion services.[39] A prominent medical practitioner interviewed by Human Rights Watch, who asked to remain anonymous due to the subject matter of this report, stated that, “[there] is still a fear of being labeled as an abortionist, a fear of the extremist groups.”[40] Interviews with other healthcare providers suggested that many not only fear being targeted by anti-choice groups, but also the social stigma that may accompany being identified as an abortion provider.

Research from other countries where abortion is only legal in limited circumstances suggests that women will continue to face obstacles in accessing services to which they are legally entitled until the government regulates access and actively addresses the stigmatization of service provision among medical practitioners, including by enforcing strict confidentiality measures for both patients and providers.[41]  

Inadequate, Inaccurate, and Misleading Information

Violations of the right to impart, seek and receive information have been common features of Ireland’s legal framework on abortion, and Ireland has both been criticized by the UN Human Rights Committee and found to be in violation of the European Convention on Human Rights by the European Court of Human Rights for its legal measures interfering with access to information.[42] 

Several international human rights treaties to which Ireland is a party include the obligation to respect and ensure the right to information also as it relates to the right to health.[43] The U.N. Committee on Economic and Social Rights, in its general comment on the right to health, explicitly recognizes the “special importance of this issue in relation to health.”[44] The Committee also recognizes the obligation of states to disseminate health-related information, including with regard to sexual and reproductive health.[45]

The 2003 World Health Organization guidelines on safe abortion set out in detail the information and confidentiality requirements for crisis pregnancy counseling that would allow women to make decisions in an informed and autonomous manner, in accordance with their human rights.[46]

The Irish government routinely violates women’s human right to access health-related information on a number of grounds. Firstly, it fails to ensure access to information about abortion services in Ireland in those circumstances permitted by law, and it does not adequately inform women and providers about their rights to confidentiality and health information. It further fails to ensure that women are able to access accurate information about abortion and services legally available outside of Ireland. Finally, it fails to counter the often blatantly false and potentially damaging and dangerous information about abortion provided by unregulated agencies that oppose women’s access to safe and legal abortion. These failures not only violate women’s right to access health-related information and services, but ultimately their rights to health, physical integrity and equality and nondiscrimination.

Lack of Information about Legal Abortion in Ireland

Human Rights Watch research suggests several reasons why access to currently legal abortion is so severely curtailed in Ireland, but the one of the clearest ones is undoubtedly the Irish government’s failure to clarify when a legal abortion may be performed and to provide information to women and healthcare workers about this right and the consequent availability of the service.

Human Rights Watch found that many medical practitioners do not know what services they may lawfully provide to women and what the standard of medical care should be when an abortion is performed in Ireland. Service providers also do not know when they can advise their clients to request an abortion. Dr Michael Geary, head of the largest maternity hospital in Ireland suggested that “it is not absolutely clear-cut [when an abortion can be performed to save the life of the woman].”[47]

The Medical Council, a statutory body established in 1979 to regulate the medical profession and protect the interest of the public in Ireland, is supposed to provide guidance on ethics and is responsible for disciplining those doctors who breach the required standards of conduct and behavior.

The Council’s guide on ethics does include a reference to abortion, acknowledging that it is legal in Ireland when there is a substantial risk to the life of the woman.[48] It however completely fails to provide further guidance to healthcare workers and refers to a submission made by the Institute of Obstetricians and Gynecologists to the All-Party Oireachtas Committee in 2000. The relevant portion of the submission is reprinted in the guide. The submission fails to refer to the risk of suicide as a ground to legally terminate a pregnancy.[49] It states that an abortion may only be performed “at a stage in pregnancy where there is little or no prospect for the survival of the baby, due to extreme immaturity”, and where the “failure to intervene may result in the death of both mother and baby.”[50] It fails to provide detailed guidance to doctors who are required to make these assessments, and it appears to value the life of the fetus over that of the woman. As noted by a member of the Human Rights Committee in the case concerning the adolescent girl in Peru who was forced to carry through an anencephalic pregnancy,[51] ‘[i]t is not only taking a person’s life that violates article 6 [the right to life] of the Covenant but also placing a person’s life in grave danger, as in this case.”[52] In this way, for purposes of adequate policy-making, the right to health and the right to life should be seen by the state as part of a continuum rather than as two separate concerns, in particular when addressing health conditions that pose a grave danger to a person’s life.

The failure of the Irish government to ensure that women have access to information about when legal abortions may be obtained in Ireland clearly violates their right to health. The UN Committee on Economic, Cultural and Social Rights has articulated the positive obligation on the part of the state to disseminate information about sexual and reproductive health, including through information and education campaigns.[53]

Obstacles in Access to Information about Abortion Services outside Ireland

The failure of the Irish government to ensure that women have access to abortion-related information means that many women struggle to access timely, accurate, and complete information about legal abortion services abroad. As a result, they experience delays in accessing care, which heightens the possibility of health complications from the intervention.[54] The delays also contribute to the emotional distress that many women experience.

Aoife C was living in a rural part of Ireland when she got pregnant. She described herself as “very distant from sources of information.”[55] She was unable to get any information about abortion and had to wait until she started university in Dublin before she was finally able to find out about services and travel to the UK, alone and extremely distressed. As a result of the delay, she was almost 28 weeks pregnant when she finally had an abortion.[56] Under UK law, a pregnancy of over 24 weeks may only be terminated if two doctors agree that a woman’s health or life is gravely threatened by the continued pregnancy or if the fetus will be severely handicapped.[57] For terminations below 24 weeks, the test is less strict, and a pregnancy can be terminated if the continued pregnancy is likely to prejudice the physical or mental health of the woman and her existing children.

Sarah B, a university educated woman, told Human Rights Watch about her experience, stating that, “information wasn’t easily available ... it was really hard to make the right connections.”[58]  

The Irish government has failed to take steps to inform women of their right to travel. To the contrary, it has historically sought to limit women’s access to information about abortion abroad, and at one time, banned all information related to foreign abortion services. The European Court of Human Rights at the time found Ireland to be in violation of its human rights obligations regarding access to information.The European Court of Human Rights noted that limiting access to information created a health risk to those women who, due to inadequate counseling, sought abortions at a later stage in their pregnancy, or who were not seeking post-abortion care. The Court also acknowledged the potentially discriminatory effect of the law, in that it “may have had more adverse effects on women who were not sufficiently resourceful or had not the necessary level of education to have access to alternative sources of information.”[59]

The 1995 legislation, ostensibly enacted to give effect to the constitutional amendments guaranteeing the right to travel and information and to bring the law more in line with the Open Door ruling, in fact places far-reaching curbs on the manner in which information can be given and almost inevitably delays access to services. For example, information may only be given during a face to face meeting. Service providers are required to prioritize the prescripts of the law over caring for their patients. A researcher and activist described how legal constraints on the provision of information, as provided for in the Information Act, negatively impact the provision of care:

[Counselors] use a very careful script to adhere to the legal constraints, but then women don’t always get the service they need.[60]

Although the internet now means that many women can access information about abortion services abroad without having to meet with a service provider, and in some ways the Act has become obsolete, it continues to discriminate against marginalized, resource-poor, or rural women who do not have ready access to the resources provided by the internet. Since information may not be provided telephonically, access for those women and for anyone else without access to transport, is further limited. Information may also not be displayed “in or at a place to which the public have access.”[61] This includes billboards and other forms of public advertisements. For some women, these forms of information may be the only way in which they are able to find out about available services.

Barriers to information are higher in non-Irish and in resource-poor communities. A service provider who assists African immigrant women indicated that her clients encountered particular problems in securing information about abortion services. She confirmed that immigrant women experienced a great deal of “confusion about how you can access information.”[62] A community activist raised similar concerns about working class and poor women, stating that a lack of information was “the biggest barrier. ... [they] wouldn’t be aware of how to get information ... I give them information in a way that they can give it to others.”[63]

The law requires that information about abortion be provided without any advocacy or promotion of abortion.[64] The Act also explicitly makes it an offence for service providers to make direct referrals for abortion, even where women make an autonomous decision to terminate a pregnancy after receiving information on all options.[65] A service provider described how these limitations prejudice women: “We cannot make direct referrals, so again distressed women are not helped. We have to send them away with a list of clinics to call. It’s very confusing [for the women] to give them information, but with no follow through.”[66] 

A community organizer who has spoken to many women in need of services added: “It adds to the pressure when they ... realize that they still have to call the clinic, book the flight, it just adds to the climate of fear.”[67]

Unregulated Agencies

The difficulty in accessing full and accurate information about abortion, and the strict regulation imposed on bodies that provide what limited information on legal abortion services they can, is further exacerbated by the existence of unregulated agencies that actively provide misleading or inaccurate information about abortion and related services in their efforts to delay or prevent abortions. These agencies misrepresent their services as neutral sources of information about crisis pregnancies and all available options, luring in women seeking information about a full set of options.[68] 

The 1995 act regulating the provision of abortion-related information does not apply to service providers who do not give abortion-related information. As a result, women who seek accurate information about all their options are at risk of receiving inaccurate, untruthful and misleading information, or in many cases, are denied information about abortion services altogether.

Claire A, a 29-year-old woman, described her experience to Human Rights Watch:

I checked in the Golden Pages [an Irish directory of products and services], and there was the first advert, called British Alternatives. I was very devastated that I was in this situation and I was afraid of getting a doctor who was unsympathetic. I called them and told them I wanted an abortion and I needed to know how far along I was. They made an appointment for Saturday ... the woman started to ask about adoption—I wanted to leave but didn’t feel that I could. She then put a video on for me and she left the room, it was ultrasound pictures and pictures of mothers. Then she came back and she put a model of a small fetus in my hand ... told me to name my baby, asked me how I would feel if I killed the baby ... Nothing tipped me off about whether they were pro-life. I was in a state and just looking for something friendly. British Alternatives sounded very friendly.[69]

While researching what information such agencies were disseminating to clients, Sinead Ahern from Choice Ireland, a Dublin-based organization advocating for women’s right to access safe and legal abortions within Ireland, approached an agency undercover: 

I told them that my last period was five weeks ago, precisely ... so the first thing they did was to ask what I would do, and I said that I’d probably terminate.... So she pulled out this sheet that was ostensibly a consent form from Australia. It said that I understand that I most certainly will need a hysterectomy ... that I might end up with the need for a colostomy bag.... That I won’t hold the doctor liable for the infection that I’d certainly get.... Next thing was a list of side-effects.... Breast cancer, cervical cancer ... [it said] most women end up with infections, infertile.[70]

She described the tactics used by these “rogue” agencies to pressure women not to terminate their pregnancies:

She said ... that I’d become promiscuous, or frigid, one of the two [after an abortion].... That most relationships break up.... That is it likely to cause congenital depression, that is not only would I get depressed, but also my family.... That I would be at increased risk of abusing any other children I might have or get.... That it caused tearfulness and sighing.... Then she showed me a video of ultrasounds, and of a doctor explaining what I now know is a very late term abortion procedure ... she showed me the instruments. Then she showed me a plastic fetus the size of a pen ... and told me that’s what my baby looked like ... the plastic fetus was sucking its thumb and had eyelashes.[71]

Claire C was under the impression that the agency she sought advice from would give her information and counseling about all her options. Instead, she was given misleading information, similar to that given to Sinead Ahern. After she left the agency, people from it “harassed me for a few weeks—they called every couple of days.... I stopped answering [calls with] withheld numbers. They would ask, ‘Is your baby still alive? Have you killed it yet?’”[72] Jane H, who was also duped by a misleading advertisement, expressed her concern about the current lack of regulation of agencies providing crisis pregnancy counseling, indicating that it was extremely difficult to ascertain which agency would provide impartial information.[73]

Jane H and her boyfriend were also misled by an advertisement. She described the information provided by the agency as “all those lies”:

We went to the appointment and they separated us. I think they weren’t used to girls coming with their boyfriends, so they separated us. One person spoke to each of us.... From what I remember, they said I’d probably never have kids [if I had an abortion], that we’d probably split up.... We didn’t see each other that whole time.... It was two hours.... They said your family is going to reject you.[74]

Interpretations of international law unequivocally support the conclusion that decisions about abortion should be made by pregnant women, and them alone. The state must ensure that women are able to exercise their full range of human rights, and the Irish government’s failure to regulate the provision of information to protect women from misleading and inaccurate information, unreasonably interferes with the right to health and their right to information. The UN Committee on Economic, Cultural and Social Rights has explicitly recognized the obligation of the state to ensure that third parties do not limit access to information.[75]

Fetal Abnormality Pregnancies

In (EU country where abortion was performed) ... you don’t feel that the system is against you. I had a sense that they were looking after me and my health.
— Aisling J, Dublin, August 26, 2008

Women who find out that they are carrying a fetus with severe genetic abnormalities face additional challenges, including the stress of unexpected emotional, physical, financial, and other consequences of dealing with a special needs pregnancy. In Ireland, they do so without any support from the state. Not only does Irish law prevent women with severe fetal abnormality pregnancies from accessing legal abortion services at home should they so choose, it also does not facilitate screening for fetal abnormalities for pregnant women in the first place.

The lack of consistent access to screening is of particular concern as fetal abnormality pregnancies can have a detrimental effect on the physical health of the pregnant woman, especially as the pregnancy progresses, in addition to the emotional stress that comes with dealing with a difficult pregnancy without support. Early detection and swift intervention is essential, and delays have an effect on women’s ability to exercise their right to health, both physical and mental.[76] 

These medical facts, while uncontested in Ireland, have not translated into policies and practices that ensure that all pregnant women have routine access to antenatal care that includes screening for fetal abnormalities, or that they may choose to terminate a pregnancy that can severely endanger their health. The general stigmatization of abortion exacerbates a situation that is already painful. A clinical midwife specialist at the largest maternity hospital in Dublin who has dealt with fetal abnormality pregnancies for more than a decade, recalled the distress of the family members of a 17-year-old daughter carrying an anencephalic pregnancy:[77] “The father said, ‘a month ago, if you’d asked if I was for abortion, I would have said no. But now I am in a society that expects my daughter to have this pregnancy!’”[78]

There is no national protocol that regulates antenatal screening, although the Royal College of Gynaecologists recommended in 1997 that ultrasound screening for abnormalities be offered to all pregnant women. A 2006 survey of maternity units in Ireland found wide variations in practice, and recommended that a standard national protocol be developed. It also indicated that a national debate on ultrasound screening for fetal abnormality was urgently needed.[79]

If a woman wishes to terminate a pregnancy with fetal abnormalities, early detection is preferable, both for the safety of the procedure itself, and to minimize the physical and emotional health consequences for the pregnant woman. Moreover, an early termination allows those women who wish to do so, to attempt having a healthy pregnancy sooner, with potentially mitigating effects on their emotional health. A UK service provider informed Human Rights Watch that the “majority of [Irish] women [we see with pregnancies with fetal abnormalities] are post twenty weeks when they come. In the UK, the terminations are earlier.”[80]

Aisling J encountered several obstacles in accessing diagnostic tests throughout the early part of her pregnancy, and therefore discovered relatively late that the fetus she was carrying had spina bifida[81] and hydrocephalus[82] and could not survive. She explained the problems she had met with:

I had the first scan after a long waiting time, so had the scan at about 16 weeks.... They said everything was fine. I saw the consultant at this visit.... He was a male doctor, extremely quick and dismissive. I was aware of the diagnostic tests I could request.... The doctor was extremely discouraging when I asked for information. He was very defensive ... why these tests?  Did I know they could lead to an abortion? Did I know they could be wrong and so I could abort a healthy child?”[83]

Aisling paid for the tests herself and also requested a second scan, to be conducted at twenty weeks, “I called the Ultra Sound Department and was categorically told no.... I was not referred to anyone else either.”[84] She eventually made arrangements to have the scan done while on vacation in a European country, where she received the devastating news that the fetus would not survive. She elected to terminate the pregnancy. She told Human Rights Watch: “I was very angry. I felt let down, maltreated.”[85]

A medical practitioner interviewed by Human Rights Watch, who did not want to be identified, inadvertently illustrated the cruelty of a system that, because abortion is illegal, fails to provide sensitive support and care:

With fetal abnormalities, even if the [pregnancy] is not compatible with life, I would not positively offer an abortion. [I would ask] are you OK with continuing the pregnancy?[86]

There is little, if any, support and assistance provided to women who are grappling with complex and traumatic decisions. For pregnant women and their partners, the discovery that the fetus may not survive, may only live a short time after birth, or may be severely disabled, is devastating. A UK service provider who counsels women and couples, including from Ireland, describes it as “a horrendous situation.”[87] She stated that women in the UK are able to access “sympathetic care ... with healthcare workers [who] are supportive of their choices.”[88] For Irish women, “there is not a lot we can do to break the isolation that they experience.”[89] Irish service providers confirmed that once a diagnosis has been made, there is no clear pathway of care, also post-procedure.[90] Aisling J described her experience afterwards:

When I came back, I rang the hospital and asked for follow up care.... I told them that I had a therapeutic abortion and asked about genetic testing. They just said to me, come back when you’re pregnant again.[91]

Financial Barriers

Poor women—frankly, they’re stuffed [i.e. they have no options] unless they know agencies who will help them [raise money to travel and for the abortion]
— Ann Furedi, Chief Executive Office, British Pregnancy Advisory Service, London, August 20, 2008

All the women interviewed for this report identified the costs associated with traveling as their most immediate and urgent concern once they had decided to have an abortion. Sarah B was 24 years old when she traveled to the UK for an abortion. She was a student and working part-time as a waitress. She described her experience to Human Rights Watch, “First and foremost was the money thing—I was so broke, I was up to my eyeballs in debt ... on a waitress’s salary. I was just, how am I going to do this?”[92] 

Claire A was also a student when she had an abortion. She stated “there was panic over the money – there was a lot of panic. [It was] very stressful.”[93] Aoife C was 16 years old and living in a rural part of Ireland. She “had no money, so I had to go to my ex-boyfriend, [which was] very hard. His first line was ‘Are you sure it’s mine?’ It was very humiliating. He had to involve his brother, who was appalled and even now ... he is still appalled at me when he sees me.”[94]

The Calthorpe Clinic in Birmingham, UK provided Human Rights Watch with a breakdown of the costs of an early medical abortion (a non-surgical procedure using medication to induce a miscarriage),[95] which include the costs of a consultation, €100, and the procedure, €510. Abortions performed after 15 weeks cost €870.[96] British Pregnancy Advisory Services (bpas) charges £459 (€535) for an early medical abortion and £800 (€932) for an abortion preformed in late gestation.[97] 

These costs do not include other direct costs, such as travel and accommodation, or indirect costs, including childcare, loss of income and the costs of a traveling companion. Irish service providers estimated the total costs to be between €800 and €1000.[98] By comparison, the median salary in Ireland fluctuates around €30,000 per year, depending on the type of job, or approximately €580 per week.[99]  For someone living under the poverty line, the cost of an abortion could easily represent more than a monthly salary.[100]

Service providers interviewed by Human Rights Watch confirmed how difficult it is for many women to raise the money to travel and the lengths that some must go to to ensure their access to safe and legal abortions. A community activist described the situation of the women she works with: “Most have to borrow money from money-lenders.... Young women, it’s not easy for them to get hold of €1000 – they go to the black market, to loan sharks.”[101] Women who borrow money from informal sources may also find themselves at risk of violence if they cannot repay loans: “Women in poverty have been loaning money from loan sharks.... There are circumstances where they have been violently beaten because they cannot afford to repay.”[102]  

For women who are in the asylum seeking process in Ireland, money is even more difficult to borrow, earn or find.[103] The majority of such women are housed in special reception centers operated by the Reception and Integration Agency, Department of Justice, Equality and Law Reform. They receive an allowance of just €19.10 per week, and an additional €6.90 per child per week.[104] They do not have the right to work under Irish law to earn further income. The costs of traveling to obtain an abortion are plainly out of reach for them, unless they are willing to take drastic action.

Asylum seekers are in a particularly vulnerable position. Often isolated, without family and other social support, they fear the consequences of seeking permission to leave the country to have an abortion. They also face additional costs as they have no travel documents, and must therefore apply and pay for emergency temporary travel documents, which are issued by the Department of Justice, Equality and Law Reform. They will also have to apply and pay for visas to enter the UK, or Schengen visas to enter into a European Union (EU) country. Currently the cost of a UK visa is £65 (€72).[105] Application fees for a Schengen visa to the Netherlands cost £60 (€67).[106]

A service provider, who spoke to Human Rights Watch on condition of anonymity, described the situation of a young female asylum seeker she had worked with:

She could not legally leave the country. Her difficulties were that she didn’t know where to go ... money and her legal status. We made the call to Holland ... she needed to get a re-entry visa to return and to apply for a Schengen visa.... She needed a temporary travel document from the Department of Justice—we had a contact there—not sure how someone without a contact would do this.... It took a whole month to organize this. She was just over 12 weeks pregnant when she went to Holland. There were fees attached to the issuing of all the documents and there was no funding available for this.[107]

Mary E, a young woman from an African country, had already applied for asylum when she became pregnant and decided to terminate her pregnancy. For her, “money was a big concern.”[108] She was aware of the costs and difficulties associated with applying for permission to travel, having “known other women in the same process for whom the help came too late.”[109] Struggling to raise the costs of travel and the abortion, “it took six weeks to get the money together,” Mary couldn’t afford a further delay or any additional costs. She decided to “borrow” the passport of a friend, fully aware that if she was caught she would face immediate deportation.

Another service provider confirmed that their clients had experienced particular difficulties on getting entry visas to the UK due to a lack of information about how to apply for the visa and what documents are required. She explained that they had pressed the Crisis Pregnancy Agency (CPA) to push for changes to this with the Department of Justice and to agree on a procedure with the UK. However, she concluded that the Department of Justice was unwilling to come up with a policy to cover all women and persisted in treating each application as a new and separate case.[110] To date, the CPA has not formally addressed this issue with the Department of Justice.

The position of Traveller women is equally difficult. The Travellers are an ethnic minority, indigenous to Ireland, and have been described as “one of the most marginalized and disadvantaged groups in Irish society.”[111] The UN Human Rights Committee expressed its concerns about the “generally lower living standards of members of this community, their low levels of participation in national, political and social life and their high levels of maternal and infant mortality.”[112] The committee urged the Irish government to improve access to services for Travellers, including to healthcare services. One service provider Human Rights Watch spoke to had assisted eight women with unwanted pregnancies over a period of four years: “None chose a termination – only because of the money.”[113] She went on to describe why none of the women were able to raise the money to travel:

All of them had children already, on average two children. [They are] living with a partner on social welfare or on a government funded training course. The cost of traveling is just not an option.[114]

 

The Covenant on Economic, Social, and Cultural Rights prohibits discrimination in the enjoyment of the rights protected by the covenant, including specifically on the ground of property. The Committee on Economic Social and Cultural Rights has clarified that “[p]roperty status, as a prohibited ground of discrimination, is a broad concept and includes ... personal property (e.g., intellectual property, goods and chattels, and income), or the lack of it.”[115] The restrictive access to abortion information and services within Ireland clearly operates as a particular barrier for women without a certain level of personal property, which, in some circumstances, would constitute prohibited discrimination.

Emotional Distress

The travel part is so difficult. I don’t think that people know this. There are a lot of people worse off than me, but it is still so traumatic even if you can afford it.
— Sarah B, Dublin, August 25, 2008

Women interviewed for this report described a profound and pervasive sense of shame and guilt caused by the stigma attached to abortion in Ireland. Being forced to leave their homes to have an abortion reinforced these feelings. Sarah B described what she called “the shame factor ... having to lie to everyone ... the lies and the shame make you feel like you’re doing something really wrong, like a drug dealer.”[116] 

The distress the women we interviewed felt was profound and in many cases linked to the reluctance on the part of the Irish government to address the issue of abortion. Having to travel abroad for a procedure at a time when many women are already in distress because of an unwanted or unhealthy pregnancy was a major source of anxiety. Sarah B explained that “the travel part is so difficult. I don’t think that people know this.... It is still so traumatic even if you can afford it.”[117] For Aoife C, who was just 16 years old, it was her first trip out of Ireland. She stated that she “was just really alone and at the mercy of a system that had no knowledge of you. I felt completely abandoned. I felt that I might not survive it”[118].

Siobhan G described an equally harrowing experience. Siobhan was pregnant with twins when she discovered that both had fatal birth defects:

I was forced to leave home and do everything in secrecy...  I was made to feel that I was doing something wrong.[119]

Megan H also described the trauma of terminating her pregnancy in the UK. Antenatal tests indicated that the fetus had Edwards syndrome, which leads to severe physical and mental disabilities:[120] “I was all over the place.... Then [after an initial visit to an Irish clinic] I was on my own, I had to contact the place, make my own travel arrangements, hotel arrangements.”[121]

Invisible Women: Those who Cannot Overcome Obstacles to Travel

Seventy percent of them have access to the net, they have money – so they will manage to get there ... there is a desperate thirty percent and it’s a huge mess. No money, no travel documents, they may do something to stop the pregnancy.

Linda Wilson Long, Head of Counselling Services, Well Women Centre, Dublin, August 26, 2008

Women who cannot travel are faced with a bleak and lonely choice—continue with an unwanted pregnancy or have an illegal and potentially unsafe abortion. This group of women is difficult to access, with few willing to expose themselves to the risk of criminal prosecution or admit that they contemplated terminating a pregnancy, once their child has been born.

Interviews conducted by Human Rights Watch suggest that many women have no choice but to continue with unwanted pregnancies. One experienced practitioner explained that many women see through crisis pregnancies “because they can’t afford the abortion.”[122] The director of a community center in central Dublin described the distress of one such woman:

I can recall one woman here, and she already had six children, and she just put her face in her hands and said, ‘oh no, I’m having twins’ and she just cried and cried.... The devastation in her face, I’ll never forget that.... But there was nothing that she coulddo.[123]

It is almost impossible to find accurate information about the prevalence and extent of illegal abortions in Ireland. The legal restrictions on abortion, stigma, fear of prosecution and attitudes of healthcare workers all prevent those women who have had illegal abortions in Ireland from seeking post-abortion care and disclosing information to healthcare providers and others. As Dr Juliet Bressan described to Human Rights Watch, “Hospitals here tend to be quite judgmental ... generally very anti-choice ... generally women only go [for post-abortion care] when they are bleeding ... maternity hospitals are actively anti-abortion.”[124] 

Irish service providers interviewed by Human Rights Watch all expressed concern that women were resorting to unsafe backstreet abortions: “we feel anecdotally that ethnic communities are having to find their own solutions ... we have had one young woman who told us that she had had the TOP [termination of pregnancy] in Dublin, but wouldn’t tell us who had done it. We had deep concerns about how the woman had been treated.”[125] In 2004 the media reported that the Garda, the Irish police, were investigating reports concerning two illegal abortions in Dublin.[126]

A community worker working with Traveller women described the difficulties they face in a community where abortions are considered “very unacceptable.”[127] The community development worker agreed to ask the women she had assisted whether they would be willing to speak directly to Human Rights Watch. None were. The community worker told Human Rights Watch about the experience of one young woman who continued with her pregnancy:

The child is now seven or eight months old. The woman is very, very unhappy. She nearly had a termination. Her relationship has ended, she has three small children. She planned to go to college, now she cannot go for another three or four years as traditionally they [Traveller women] are solely responsible for child care ... huge pressure on mental health, many children and financial pressure.[128]

A service provider for women in treatment for drug addiction described similar problems:

Women who are in treatment for drug addiction can’t just leave.... It’s mandatory daily treatment.... Just the organizing [of the trip] is a problem.... The existing children [that have to be cared for] and that’s all tied up with the fact that the termination is not really something that you want to talk about.... There are women who just go through with the pregnancy.... And the baby ends up in [public] care from birth.[129]

Access to Abortifacients over the Internet

Advances in both medicine and technology have provided potentially safer options to women who are unable to travel in that they might purchase abortifacient drugs over the internet, though this would still constitute a crime under current Irish law, punishable by prison. Access also still depends on the resources available to the individual woman—both financially and in terms of her access to information. Even these newer options come with considerable delays and no medical review and safeguards.

A medical practitioner who, for research purposes, bought abortifacient drugs over the internet to test when and how they arrived, told Human Rights Watch:

The package is very complicated.... It says on the back of the package [the outside] that it is misoprostol, announcing ‘here is your abortion package’ almost.... It is delivered by couriers.... So it is not appropriate for women who are not internet literate, who don’t have a credit card, and who don’t sit in an office where they don’t mind having an abortion package delivered.... Plus it’s late ... it took three weeks to get to me after I ordered it.[130]

Service providers also expressed confusion about whether acquiring an abortifacient over the internet contravened the provisions of the Offences Against the Person Act, leading women who obtained medication in this way to be more reluctant to seek post-abortion care and counseling.

Crisis Pregnancy Agency

One of the Irish government’s key responses to abortion was the establishment of the Crisis Pregnancy Agency (CPA) in 2001, a year that saw a particularly high number of women from Ireland traveling to the UK for abortions.[131] The CPA was described by its first chairperson as the first attempt by the government to comprehensively address “the long standing reality”[132] of crisis pregnancy in Ireland, and in the 2003 report to the UN CEDAW committee, the government pointed to establishment of the CPA as part of the steps taken to realize the right to health without discrimination.[133]  In 2007, the government again highlighted the establishment of the CPA, this time in its third periodic report to the Human Rights Committee, indicating that the CPA had been established to fulfill article 6 of the International Covenant on Civil and Political Rights on the right to life.[134]

However, the mandate and structure of the CPA are mired with weaknesses that prevent it from adequately addressing the many abortion-related issues set out in this report, including that the CPA is a planning and coordination body with no regulatory authority, and the government is not obliged to follow its recommendations.

Another serious problem is that the agency, by its mandate, is geared towards limiting the autonomous reproductive decision-making that women have a human right to exercise, rather than supporting it. The CPA identifies parenting as the “optimal outcome for any woman,”[135] and one of its key objectives is to reduce the number of women who choose abortion, rather than adoption or parenting as the outcome of a crisis pregnancy. Apart from infringing on women’s human rights, this mandate hampers the agency’s ability to respond fully to the needs of women with unwanted pregnancies, including advocating for access to a full range of reproductive health services.

As a result of its limited mandate, the CPA has focused much of its attention and resources on funding counseling services and post-abortion care. In 2008, it spent €3.7 million on support and services for women with crisis pregnancies. €2.5 million of this amount was allocated to crisis pregnancy counseling and post-abortion care. The CPA claims that it has increased the provision of crisis pregnancy counseling by 55 percent since 2002.[136] Since the government does not gather information about abortion services in Ireland, nor about the number of women traveling for services, it is not possible to assess to what extent the agency is responding to the full need for post-abortion care.

The CPA has also delayed in responding to concerns raised by civil society about “rogue” agencies. The current legislation, while regulating the provision of abortion-related information, does not regulate the provision of any other information. The gap in the law has allowed the “rogue” agencies to provide misleading and inaccurate information to women and there have been calls on it to make recommendations to the government to prevent women from being duped by these agencies. The CPA only announced in July 2009 that it would undertake a public information campaign warning women about the “rogue” agencies. It acknowledged that it had received 67 complaints in a nine month period from women who had been victims of these agencies.[137]

[27]Human Rights Watch interview with Dr Mary Favier, Doctors for Choice, Cork, August 28, 2008.

[28] Ibid.

[29] Media accounts detail that Professor John Bonnar, Emeritus Professor of Obstetrics & Gynaecology at Trinity College, Dublin, during the course of his career had terminated small number of pregnancies in the context of saving a pregnant woman’s life, but it is not clear that any of these were classified as abortions. Dearbhail McDonald, “Doctors fear abortion charge if they direct patients abroad,” Irish Independent (Dublin), December 12, 2009.

[30] The outcome document from the International Conference on Population and Development (ICDP), held in Cairo in 1994.

[31] ICPD Programme of Action, para. 8.25.

[32] See e.g. Report by the Special Rapporteur on the Right to the Highest Attainable Standard of Health, UN E/CN.4/2004/49, 16 February 2004, para. 30.

[33] The UN Committee on Economic, Social and Cultural Rights, which is the authoritative body established to monitor states compliance with their obligations under the ICESCR, issued General Comment No. 14 on the right to the highest attainable standard of health, guaranteed in Article 12 of the ICESCR  (E/C.12/2000/4, August 11, 2000.). The Committee set out that a state must ensure health care facilities and services are available in sufficient quantity; accessible to everyone without discrimination, including economically accessible; culturally acceptable, as well as scientifically and medically appropriate and of good quality (para. 12).

[34] Anencephaly is fetal malformation in which the brain and spinal cord fail to develop in utero. When the outcome is not a stillbirth, death usually occurs within hours or days after birth. Jerrold B. Leikin, MD and Martin S. Lipsky, MD (eds.), American Medical Association Complete Medical Encyclopedia (New York: Random House Reference, 2003), p. 160.

[35] KL v Peru (2005), Comm. No. 1153/2003, UN Doc. CCPR/C/85/D/1153/2003.

[36] UN Committee against Torture, Consideration of Reports Submitted by States Parties under Article 19 of the Convention: Concluding Observations of the Committee against Torture: Nicaragua,” CAT/C/NIC/CO/1, June 10, 2009, para. 16

[37] Report by the Commissioner for Human Rights Mr Thomas Hammarberg On His Visit to Ireland,26 – 30 November 2007,adopted Strasbourg, April 30, 2008, CommDH (2008),  p.36.

[38]See for example, Human Rights Committee, “Concluding observations of the Human Rights Committee on Ireland,” July 24, 2000, Document A/55/40[Vol.I](Supp.): “The Committee is concerned that the circumstances in which women may lawfully obtain an abortion are restricted to when the life of the mother is in danger and do not include, for example, situations where the pregnancy is the result of rape. The State party should ensure that women are not compelled to continue with pregnancies where that is incompatible with obligations arising under the Covenant (art. 7) and General Comment No. 28.” (paras. 444 – 445) and Human Rights Committee, “Concluding observations of the Human Rights Committee on Ireland,” CCPR/C/IRL/CO/3, July 30 2008: “The Committee reiterates its concern regarding the highly restrictive circumstances under which women can lawfully have an abortion in the State party. While noting the establishment of the Crisis Pregnancy Agency, the Committee regrets that the progress in this regard is slow. (arts. 2, 3, 6, 26). The State party should bring its abortion laws into line with the Covenant. It should take measures to help women avoid unwanted pregnancies so that they do not have to resort to illegal or unsafe abortions that could put their lives at risk (article 6) or to abortions abroad (articles 26 and 6)’, para. 13. See also Concluding Observations of the Human Rights Committee on Monaco, CCPR/C/MCO/CO/2, December 12, 2008 para.10.

[39]The prevailing assumption among policy makers and some medical providers in Ireland seem to be that abortion, if available, would have to be provided by gynecologist or obstetric specialists. This is not an accurate reflection of international standards. In 2003, the World Health Organization’s safe abortion guidance recommended that abortion services be provided at the lowest appropriate level of the healthcare system. It states that vacuum aspiration can be provided at primary-care level up to 12 completed weeks of pregnancy and medical abortion up to 9 completed weeks of pregnancy, and that mid-level health workers can be trained to provide safe, early abortion without compromising safety. It includes as mid-level providers: midwives, nurse practitioners, clinical officers, physician assistants and others. Training includes bimanual pelvic examination to determine pregnancy and positioning of the uterus, uterine sounding, transcervical procedures, provision of abortion and skills for recognition and management of complications. World Health Organization, Safe abortion: technical and policy guidance for health systems. (Geneva: WHO; 2003).

[40] Human Rights Watch interview with [name withheld], Dublin, August 27, 2008.

[41] See e.g. Human Rights Watch, “The Second Assault: Obstructing Access to Legal Abortion After Rape in Mexico,” in particular section V. See also Human Rights Watch, “My Rights, and My Right to Know: Access to Therapeutic Abortion in Peru,” in particular section V.

[42]See UN Human Rights Committee (HRC), “UN Human Rights Committee: Comments: Ireland,” August 3, 1993, CCPR/C/79/Add.21, para. 15, and Case of Open Door and Dublin Well Woman v. Ireland, Application no. 14234/88; 14235/88, Judgment of October 29, 1992, Series A No. 246-A, p. 28.

[43] See Article 19 of the ICCPR and Article 10 of the ECHR.

[44] Committee on Economic, Social and Cultural Rights, “General Comment 14: The right to the highest attainable standard of health”, E/C 12/2000/4, August 11, 2000.

[45] Ibid., para. 36.

[46] World Health Organization, Safe abortion: technical and policy guidance for health systems, 2003, in particular Chapter 3.

[47] Human Rights Watch interview with Dr Michael Geary, Master, Rotunda Hospital, Dublin, August 28, 2008.

[48] Medical Council, A Guide to Ethical Conduct and Behaviour, Sixth Edition 2004, section 24.6.

[49] The risk of suicide was specifically identified as included within the definition of “risk to the life of the mother.” See Attorney-General v X [1992] IESC 1.

[50] Ibid., p.44.

[51] KL v Peru (2005), Comm. No. 1153/2003, UN Doc. CCPR/C/85/D/1153/2003.

[52] Ibid., p. 12.

[53] Committee on Economic, Social and Cultural Rights, “General Comment 14: The right to the highest attainable standard of health”, E/C 12/2000/4, August 11, 2000, para. 36.

[54] Abortion is generally a safe medical procedure if carried out under proper conditions. It is safest when provided within the first eight weeks of the pregnancy. As the pregnancy progresses, “[t]he relative risk of dying as the consequence of abortion approximately doubles for each 2 weeks after 8 weeks' gestation." F. Gary Cunningham, Kenneth L. Leveno , Williams Obstetrics (2005), chapter 9.

[55] Human Rights Watch telephonic interview with Aoife C, September 11, 2008.

[56] Human Rights Watch telephonic interview with Aoife C, September 11. 2008.

[57] The Abortion Act 1967, section 1. The Abortion Act also permits post-24 week abortions if the fetus “would suffer from such mental or physical abnormalities as to be seriously handicapped.” 

[58] Human Rights Watch interview with Sarah B, Dublin,  August 25, 2008.

[59] Open Door and Dublin Well Woman v. Ireland, October 29, 1992,  para. 77, Series A no 246-A, This issue was also brought to the European Court of Justice as an alleged breach of the EU rules on freedom of provision of services, Society for the Protection of Unborn Children Ireland Limited (SPUC) v Grogan C- 159/90,  [1991] ECR I-4685. The ECJ did not find a violation on those grounds, finding that the distribution by third parties of information on services was not a ‘service’ covered by EU law.

[60] Human Rights Watch telephonic interview with Catherine Conroy, September 11, 2008.

[61] Ibid., Section 4.

[62] Human Rights Watch interview with Siobhan O’ Brien Green, Migrant Women’s Health Services Project, Akidwa, Dublin, August 27, 2008.

[63] Human Rights Watch interview with Kathleen O’Neill, Dublin, August 29 2008.

[64] Regulation of Information (Services outside the State for Termination of Pregnancies) Act, 1995, Section 5.

[65] 1995 Act, Section 8 (1); It shall not be lawful for a person to whom Section 5 applies or the employer or principal of the person to make an appointment or any other arrangement for or on behalf of a woman with a person who provides services outside the State for the termination of pregnancies. Sections 9 and 10 set out the legal enforcement of the offence.

[66] Human Rights Watch telephonic interview with Rosie Toner, Director of Counselling, Irish Family Planning Association, August 25, 2008.

[67] Human Rights Watch interview with Sian Muldowney, Alliance for Choice, Dublin, August 25, 2008.

[68] Irish Family Planning Association, Rogue Crisis Pregnancy Agencies in Ireland – Anti Choice and Anti Women, (Dublin: IFPA, 2007); “Rogue pregnancy agencies accused of giving bad advice,” Belfast Telegraph, July 26 2008;  Siobhan Maguire and Dearbhail McDonald ,  “Women ‘duped’ by bogus agencies,” Times Online,   July 9, 2008, http://www.timesonline.co.uk/tol/news/world/ireland/article685118.ece, (accessed  November 12 2008);  Lara Bradley, “Counsellor offered shock anti-abortion propaganda,” The Independent, July 16, 2006, http://www.independent.ie/unsorted/features/counsellor-offered-shock-antiabortion-propaganda-132608.html (accessed November 12, 2008).

[69] Human Rights Watch interview with Claire A, Dublin, August 29, 2008.

[70] Human Rights Watch interview with Sinead Ahern, Choice Ireland, Dublin, August 25, 2008.

[71] Human Rights Watch interview with Sinead Ahern, Choice Ireland, Dublin, August 25, 2008. None of the medical claims allegedly made by this agency are supported by medical science. At 5 weeks, the product of the pregnancy is approximately the size of a large grain of rice and certainly would not have eye-lashes or developed digits. See Women’s Healthcare Topics, “5 weeks pregnant – Pregnancy week by week,” at http://www.womenshealthcaretopics.com/pregnancy_week_5.htm,  (accessed on January 12, 2010).

[72] Human Rights Watch interview with Claire C, Dublin, August 29, 2008.

[73] Human Rights Watch interview with Jane H, Dublin, August 28, 2008.

[74] Human Rights Watch interview with Jane H, Dublin, August 28, 2008.

[75] Committee on Economic, Social and Cultural Rights, “General Comment 14: The right to the highest attainable standard of health”, E/C 12/2000/4, August 11, 2000, para. 35.

 

[76] Different fetal abnormality pregnancies carry different health risks for the pregnant woman. Typical physical health consequences may include polyhydramnios, postural hypotension, premature membrane rupture, breech birth or other forms of dystocia, and amniotic embolisms. Equally important are the potential consequences on the emotional health of the pregnant woman, including anxiety, severe depression, and post-traumatic stress disorder (PTSD). See Luis Távara Orozco, Why fatal congenital malformations and rape justify a legal abortion (Por qué las malformaciones congénitas letales y la violación justifican un aborto legal)  (Lima: Centro de Promoción y Defensa de los Derechos Sexuales y Reproductivos (PROMSEX), 2008), p. 11.

[77] See description of anencephaly at note 35 above.

[78] Human Rights Watch interview with Jane Dalrymple, Clinical Midwife Specialist, The Rotunda Hospital, Dublin, August 27, 2008.

[79] Lalor, J, Devane, D, McParland, P, Ultrasound Screening for fetal abnormality in Ireland: A national survey, Irish Journal of Medical Science (2007) pp. 176 – 179.

[80] Human Rights Watch interview with Jane Fisher, Antenatal Results and Choices, London, September 4, 2008.

[81] Spina bifida is a series of birth defects in which there is incomplete closure in the spinal column. Jerrold B. Leikin, MD and Martin S. Lipsky, MD (eds.), American Medical Association Complete Medical Encyclopedia, p. 1148.,

[82] Hydrocephalus is the excessive accumulation of cerebrospinal fluid in the brain. Ibid., p. 687.

[83] Human Rights Watch interview with Aisling J, Dublin, August 26, 2008.

[84] Human Rights Watch interview with Aisling J, Dublin, August 26, 2008.

[85] Human Rights Watch interview with Aisling J, Dublin, August 26, 2008.

[86] Human Rights Watch interview with [name withheld], August 27, 2008.

[87] Human Rights Watch interview with Jane Fisher, Antenatal Results and Choices, London, September 4, 2008

[88] Human Rights Watch interview with Jane Fisher.

[89] Human Rights Watch interview with Jane Fisher.

[90] Human Rights Watch telephonic interview with Rosie Toner, Director of Counselling, Irish Family Planning Association, August 25, 2008 .

[91] Human Rights Watch interview with Aisling J, August 26, 2008.

[92] Human Rights Watch interview with Sarah B, Dublin, August 25, 2008.

[93] Human Rights Watch interview with Claire A, Dublin, August 29, 2008.

[94] Human Rights Watch telephonic interview with Aoife C, September 11, 2008.

[95] Performed up to 9 weeks of gestation at the Calthorpe Clinic.

[96] Human Rights Watch interview with Carolyn Phillips, Clinic Manager, Calthorpe Clinic, Birmingham, July 29, 2008.

[97] Human Rights Watch interview with Ann Furedi, Chief Executive of Bpas, London, August 20, 2008.

[98] Human Rights Watch telephonic interview with Rosie Toner, Director of Counseling, Irish Family Planning Association, August 25, 2008.

[99] See Payscale, “Median Salary Per Job, Country: Ireland,” at http://www.payscale.com/research/IE/Country=Ireland/Salary, (accessed on July 13, 2009).

[100] The Conference of Religious of Ireland (CORI Justice), “Income and Poverty,” at http://www.cori.ie/Justice/Specific_Policy_Issues/27-incomepoverty, (accessed on July 13 2009).

[101] Human Rights Watch interview with Mary Cumming, Northwall Women’s Centre, Dublin, August 26, 2008.

[102] Human Rights Watch interview with Sian Muldowney, Alliance for Choice, Dublin, August 25, 2008.

[103] In August 2008, statistics provided by the Reception and Integration Agency showed that there were 6959 residents in various reception centers in Ireland. This included 899 single women. 3781 families were also included, but no information was provided on the number of women in this figure.

[104] Information obtained from Refugee Information Services at http://www.ris.ie/whataremyrights/asylumseeker.asp (accessed on July 1, 2009).

[105] Information obtained from UK Border Agency at http://www.ukvisas.gov.uk/en/howtoapply/visafees/ (accessed on November 28, 2008).  Exchange rate of January 12, 2010.

[106] Information obtained from the Netherlands Embassy, UK at http://www.netherlands-embassy.org.uk/passports/index.php?i=62 (accessed on November 25, 2008)

[107] Human Rights Watch interview with [name withheld], Dublin, August 25, 2008.

[108] Human Rights Watch telephonic interview with Mary E, September 25, 2008.

[109] Human Rights Watch telephonic interview with Mary E.

[110] Human Rights Watch telephonic interview with Alison Begars, Chief Executive Office, Well Woman, August 22, 2008.

[111] National Consultative Committee on Racism and Interculturalism,  ”Travellers in Ireland: An Examination of Discrimination and Racism,” at http://www.nccri.ie/nccri-background.html  (accessed on December 7, 2008). 

[112] UN Human Rights Committee, “Concluding Observations of the Human Rights Committee: Ireland,” A/55/40, July 24, 2000.

[113] Human Rights Watch telephonic interview with [name withheld], August 29, 2008.

[114] Human Rights Watch telephonic interview with [name withheld], August 29, 2008.

[115] Committee on Economic Social and Cultural Rights, “Non-Discrimination in Economic Social and Cultural Rights,” E.C.12/GC/20, June 2009, para. 25.

[116] Human Rights Watch interview with Sarah B, Dublin, August 25, 2008.

[117] Human Rights Watch interview with Sarah B.

[118] Human Rights Watch telephonic interview with Aoife, September 11, 2008.

[119] Human Rights Watch telephonic interview, Siobhan G, September 8, 2008.

[120] Edwards syndrome (also known as Trisomy 18 syndrome) is a genetic disorder caused by the presence of an extra 18th chromosome. It is estimated that about half of pregnancies involving a fetus with Edwards syndrome end in a stillbirth.  About 20 percent of those born alive with the syndrome will die within a month, and 90 percent will die before the age of 12 months.  Jerrold B. Leikin, MD and Martin S. Lipsky, MD (eds.), American Medical Association Complete Medical Encyclopedia, p. 1239.

[121] Human Rights Watch interview with Megan H, Dublin, August 28, 2008.

[122] Human Rights Watch interview with Juliet Bressan, Doctors for Choice, Dublin, August 25, 2008.

[123] Human Rights Watch interview with Mary Cummings, Northwall Women’s Centre, Dublin, August 26, 2008.

[124] Human Rights Watch interview with Juliet Bressan, Doctors for Choice, August 25, 2008.

[125] Human Rights Watch telephonic interview with [name withheld], August 22, 2008.

[126] Indymedia Ireland, “Backstreet abortions illustrate need for free, safe and legal abortion services in Ireland,” at https://www.indymedia.ie/article/65902 (accessed on November 12, 2008); Irishealth, “Backstreet abortion probed,” at http://www.eu-health.com/index.html?level=4&id=6088 (accessed on November 11, 2008).

[127] Human Rights Watch telephonic interview with [name withheld], August 29, 2008.

[128] Human Rights Watch telephonic interview with [name withheld], August 29, 2008.

[129] Human Rights Watch interview with Joan Byrne, Saol Project, Dublin, August 27, 2008.

[130] Human Rights Watch interview with [name withheld], Dublin, August 25, 2008.

[131] According to the UK Department of Health, 5 585 women who gave Irish residential addresses had abortions in the UK in 2005.

[132] Irishhealth.com, Crisis pregnancy agency begins work, at http://www.irishhealth.com/article.html?id=3298 (accessed on December 7, 2008).

[133] UN CEDAW committee, “Consideration of the reports submitted by State parties under article 18 of Convention of the Elimination of All Forms of Discrimination Against Women, Combined fourth and fifth reports of State parties: Ireland,” CEDAW/C/IRL/4-5, 2003.

[134] UN Human Rights Committee, “Consideration of reports submitted by State parties under Article 40 of the Covenant, Third periodic reports of State parties: Ireland,”CCPR/C/IRL/3.

[135] Human Rights Watch telephonic interview with Caroline Spillane, Director, Crisis Pregnancy Agency, October 15, 2008.

[136] See http://www.crisispregnancy.ie (accessed on July 2, 2009).

[137] Kitty Holland, “Warning on biased crisis pregnancy ‘counselling’,” Irish Times, athttp://www.irishtimes.com/newspaper/ireland/2009/0721/1224250997240.html (accessed on July 26, 2009).